Although estimates of alcohol-related mortality (ARM) have
been determined for the United States and selected states (1-6),
the magnitude of ARM has not been well defined for smaller
geographic areas. To provide additional geographically specific
data, the Alcohol Epidemiologic Data System of the National
Institute on Alcohol Abuse and Alcoholism recently released a
reference manual for ARM in U.S. counties (County Alcohol Problem
Indicators (7)). The manual provides information for 3107 counties
for 1979-1985 using both underlying and multiple cause-of-death
information. This report summarizes data sources, methods, and
applications for the manual.

Data sources for the report included vital statistics from
CDC's National Center for Health Statistics, population estimates
from the Bureau of the Census, and estimates of
alcohol-attributable fractions (AAFs) from the research literature.
AAFs are estimates of the proportion of deaths from disease or
injury diagnoses that are causally linked to alcohol use or misuse
(4,7,8). Alcohol-related deaths were identified from death
certificates based on the International Classification of Diseases,
Ninth Revision (ICD-9) (9).

Data provided for each county include average death rates per
100,000 population for the following diseases and injuries:
alcoholic psychoses (ICD-9 code 291), alcohol dependence syndrome
(303, 265.2, 357.5, 425.5, and 535.3), nondependent abuse of
alcohol (305.0), cirrhosis (571 and 572.3), alcohol poisoning
(790.3 and E860), motor-vehicle crashes (E810-E825), suicide
(E950-E958), and homicide (E960-E969). Application of AAFs to
deaths from these diseases and injuries enabled estimation of ARM
for each county. Estimates of ARM caused by alcohol-related
diseases were also calculated based on multiple cause-of-death
data. County rank within state and percentile rank within the
United States based on these estimates and rates are provided. The
number of alcohol-related disease deaths, based on multiple
cause-of-death records, yields estimates of ARM that are 69% higher
than those based on underlying cause only for the same diseases.
These increases varied by disease and were less for cirrhosis (50%)
and substantially more for alcohol dependence syndrome (150%).
Because counties often have small populations with few
alcohol-related deaths in any given year, population and mortality
data for 5 years (1979, 1980, and 1983-1985) were averaged to
develop more stable annual county death rates.
(Continued on page 561)

The manual compares ARM across counties within a state and
throughout the United States. Counties in the lowest U.S.
percentile rank averaged fewer than five deaths that mention an
alcohol-related disease per 100,000 persons, and counties in the
highest percentile rank averaged more than 55 deaths per 100,000.

Determining the percentile rank of each county can assist in
ranking metropolitan areas that overlap state boundaries, such as
the tristate metropolitan area that includes New York City and
parts of Connecticut and New Jersey. Based on U.S. percentile
ranks, New York City (comprising the Bronx, Brooklyn, Manhattan,
Queens, and Staten Island) and New Jersey's Essex and Hudson
counties ranked in the highest 10% of U.S. counties for ARM (Figure
1).

Editorial Note

Editorial Note:

The estimates presented in County Alcohol Problem Indicators
use mortality data that are routinely collected at the county
level. The alcohol-related conditions used in this analysis are
based on a subset of specific causes of death for which AAFs are
available, thereby producing conservative estimates of ARM (a
national average of 54,000-83,000 deaths per year for 1979-1985).
Other approaches to estimating ARM have used more comprehensive
sets of diagnoses, resulting in less conservative definitions of
AAF and producing larger estimates (e.g., 105,000 deaths in 1987
(4)).

Mortality data are a readily available and routinely measured
indicator that permit analysis at the county level. These data, in
conjunction with other county-level characteristics, can be used by
state and local program planners and other health officials in
assessing community service requirements for prevention and
treatment services for alcohol-related disease. For example, the
Iowa Department of Public Health used county rankings of ARM to
develop a comprehensive state plan for substance abuse for
1986-1987 (10). These data can also be used to monitor local
conditions relevant to prevention efforts identified in the year
2000 health objectives (11).

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